Efficacy and safety of oral anticoagulants in patients with Afib on dialysis

Takeaway

• In patients with atrial fibrillation (Afib) on long-term dialysis, oral anticoagulants (OACs) were not associated with a reduction in the risk for thromboembolism.
• Apixaban 5 mg was associated with a lower risk of mortality vs apixaban 2.5 mg, warfarin, and no anticoagulant.
• The risk for bleeding was higher with warfarin, dabigatran and rivaroxaban compared with apixaban and no anticoagulant.

Why this matters

• Findings warrant further studies to determine the benefit-to-risk ratio of OACs in patients with Afib on long-term dialysis.

Study design

• Meta-analysis included 16 studies (n=71,877) after a search across MEDLINE and EMBASE.
• Funding: None disclosed

Key results

• Compared with no anticoagulants, apixaban (apixaban 5 mg: HR, 0.59; 95% CI, 0.30-1.17; apixaban 2.5 mg; HR, 1.00; 95% CI, 0.52-1.93) and warfarin (HR, 0.91; 95% CI, 0.72-1.16) were not associated with a significant decrease in the risk for stroke and/or systemic thromboembolism.
• Apixaban 5 mg significantly reduced the risk for mortality compared with:
  • warfarin (HR, 0.65; 95% CI, 0.45-0.93);
  • apixaban 2.5 mg (HR, 0.62; 95% CI, 0.42-0.90); and
  • no anticoagulant (HR, 0.61; 95% CI, 0.41-0.90).
• Warfarin was associated with a significantly higher risk for major bleeding vs:
  • apixaban 5 mg (HR, 1.41; 95% CI, 1.07-1.88);
  • apixaban 2.5 mg (HR, 1.40; 95% CI, 1.07-1.82); and
  • no anticoagulant (HR, 1.31; 95% CI, 1.15-1.50).
• The risk for major bleeding was higher with:
  • dabigatran vs:
    • apixaban 2.5 mg (HR, 2.07; 95% CI, 1.42-3.01), 5 mg (HR, 2.09; 95% CI, 1.42-3.09) and no anticoagulant (HR, 1.94; 95% CI, 1.44-2.62).
  • Rivaroxaban vs:
    • apixaban 2.5 mg (HR, 1.92; 95% CI, 1.25-2.94), 5 mg (HR, 1.94; 95% CI, 1.25-3.02) and no anticoagulant (HR, 1.80; 95% CI, 1.25-1.50).

Limitations

• Limited data were available on the efficacy and safety of dabigatran, rivaroxaban, and apixaban.